The UK is among a growing number of countries that are debating or have recently legalised assisted dying, primarily in western democracies. While international experience has already informed the debate in the UK, comparisons have focused on specific country examples and a narrow set of legal differences.
This briefing provides a comprehensive review of international evidence from 15 jurisdictions in 9 countries to describe a wider range of practical and operational differences in how comparable systems have set up assisted dying. We also describe the uptake of assisted dying in different jurisdictions, and how policy has changed over time in places with longer-standing laws.
The Nuffield Trust takes a neutral position on whether assisted dying should be legal. This review does not make a judgement about the effectiveness of different models.
Main findings
- There is a broad spectrum of legislation and practice across countries. Some systems apply more restrictive policies, while others have adopted more permissive frameworks, but the degree of restriction is not consistent. Some countries enforce more stringent safeguards in some areas of policy while allowing greater flexibility in others, making it difficult to categorise countries in a strictly linear way.
- People who do not have a terminal illness can access assisted dying in some countries, but not all. Of the systems we reviewed, we found no examples where eligibility became more narrow or restrictive over time, though some, such as Oregon in the US, have remained relatively consistent. Among some systems where assisted dying has been legal for over five years, eligibility criteria have expanded, notably in Canada, Belgium and the Netherlands.
- Regardless of eligibility criteria, the proportion of all deaths which were assisted deaths has increased over time in most countries, although assisted deaths make up only a relatively small percentage of total deaths in any given year (0.1–5.3% in 2023).
- In almost all systems, assisted dying is publicly funded and integrated into the health care system.
- Countries have all established clear processes and frameworks for managing assisted dying. However, safeguards and requirements vary – including how patient consent and decision-making capacity are assessed, how practitioners are trained, and which roles are permitted to provide assisted dying.
- Systems also vary in how they monitor and ensure compliance with regulations. Some countries require a review of assisted dying requests before they can be approved, while in other countries only a retrospective review of decisions is undertaken.
Differences between countries are not just procedural – they affect how individuals access and experience services, what roles and responsibilities professionals hold, and how safeguards are upheld. As assisted dying legislation is debated in the UK, the diverse experiences of other countries offer critical learning. Our future work will delve deeper into the operational and system challenges that jurisdictions have faced in implementation, with key lessons for the UK as it considers its own path.
Introduction
The UK is among a growing number of countries that are debating or have recently legalised assisted dying, primarily in western democracies. This includes France, which introduced a bill in 2024 with parliamentary discussions ongoing, and Portugal, which voted to legalise assisted dying in 2023, pending further regulation. Various forms of assisted dying are already legal in several countries and jurisdictions, including Australia, Austria, Belgium, Canada, Colombia, Cuba, Ecuador, Germany, Italy, Luxembourg, the Netherlands, New Zealand, Spain, Switzerland, and parts of the United States.
In each of these places, the way assisted dying has been implemented varies considerably. This wide range of experiences offers important learning on the set of options and practical implications that need to be considered when deliberating how legalisation might affect individuals, families, staff, and health and care services in the UK.
While a wealth of international learning has already been drawn on to inform the debate in the UK, comparisons have primarily focused on specific country examples or a narrow set of legal parameters across jurisdictions, focusing on eligibility requirements for those wishing to access assisted dying. This briefing provides a comprehensive review of international evidence to describe a wider range of practical and operational differences in how comparable systems in nine countries have set up assisted dying. We also describe the uptake of assisted dying in different jurisdictions, and how policy has changed over time in places with longer-standing laws.
Methods and approach
This report is based on a structured analysis of official documents relevant to assisted dying practices in countries where it was legalised as of 2023, including Australia, Austria, Belgium, Canada, the Netherlands, New Zealand, Spain, Switzerland, and parts of the United States. We focus on high-income OECD countries or jurisdictions with populations over 3 million. This excludes some systems where assisted dying is legal (e.g. Luxembourg, Colombia, and some U.S. and Australian states). We also exclude countries where legislation has yet to be implemented (Portugal) or where legal frameworks remain ambiguous (Germany and Italy).
We draw on a range of sources, including policy documents, official guidance, legislation, and data monitoring reports. Non-English sources were translated using DeepL Translator; translations were cross-checked against English-language literature to support accuracy and consistency (triangulation).
The briefing highlights key implementation examples rather than providing an exhaustive country-by-country review. While this output is primarily descriptive, a future publication will explore key lessons from international experiences and their implications for the UK.
The Nuffield Trust’s position on assisted dying
The Nuffield Trust is an independent health think tank. We aim to improve the quality of health and social care in the UK by providing evidence-based research and policy analysis and informing and generating debate.
The Nuffield Trust retains a neutral position on the ethics of whether or not assisted dying should be legalised, for whom, and in what circumstances. But we are committed to identifying evidence to support decision-makers in understanding the potential implications for health and care services. The focus of this briefing is not on the question of whether or not assisted dying should be legalised, but on the potential implications of a change in legislation on NHS and social care services and their workforce, as well as on patients and families.
The Nuffield Trust is well suited to take on this challenging topic, given our independence and our experience of drawing system-level lessons from international settings.
Terminology and definitions
A wide range of terminology related to assisted dying is in use, and definitions vary. In this study, we follow the approach of the Nuffield Council on Bioethics and use the term 'assisted dying' as an umbrella term for a range of situations “involving healthcare professionals in providing lethal drugs intended to end a patient’s life at their voluntary request, subject to a set of conditions”. This includes both self-administration of lethal drugs required to die following prescription by a clinician at an individual’s request (sometimes referred to medically assisted death or assisted suicide), and clinician administration of the lethal drug following a request from a patient (sometimes referred to as voluntary euthanasia).
Throughout the briefing, we use different terms for health professionals. We sometimes use the broader term ‘health practitioner’ to refer to the wider set of roles that may be involved in the assisted dying process or end of life care more generally (e.g. allied health professionals). We use ‘clinician’ when referring to roles that require certain qualifications to be involved in assisted dying (e.g. nurses, doctors).
The terms ‘review’ and ‘assessment’ refer to different things as part of the assisted dying process. We use ‘assessment’ to mean the processes carried out by health practitioners to determine whether a person meets eligibility criteria for assisted dying before the service can be provided. This is distinct from ‘review’, which is typically carried out by specialised committees or oversight bodies to ensure laws have been followed correctly.
Assisted dying practices across countries
The table below provides a comparative overview of how different systems have implemented assisted dying, highlighting key differences in legislation and practice. The spectrum and range of variation across approaches is broad – some systems have applied more restrictive policies, while others have adopted more permissive frameworks.
The degree of restriction or permissiveness observed in different systems isn’t always consistent across different aspects of policy. Some countries enforce more stringent safeguards in some areas while allowing greater flexibility in others, making it difficult to categorise countries in a strictly linear way. Nor has policy been static: while some systems have adopted broader policies from the outset, others have gradually evolved to become less restrictive over time. We discuss some of the main operational and practical differences across countries in the sections that follow. Where relevant, we identify key shifts in policy adoption since becoming legal.
1. In almost all systems, assisted dying is publicly funded and integrated into the health system
In most countries where assisted dying is legal, it is fully integrated into the broader health and social care system, meaning that it is publicly funded and provided within mainstream health care services as part of standard benefit packages.
There are some notable exceptions to this. In Switzerland, assisted dying is provided by independent, not-for-profit organisations like Dignitas, operating outside of the main health care systems. While Swiss doctors – working independently of these organisations – assess cases and prescribe medication, the assisted dying service is overseen by these not-for-profits, of which individuals must be a member and pay a fee. In the US, most government-run health insurance programmes and private health insurance policies do not cover assisted dying, though there are some exceptions (like state-funded Medicaid services in California which cover drugs used in assisted dying).
Even in systems where assisted dying is publicly funded and integrated into services, individuals may still face out-of-pocket payments, such as user charges for medication or doctor visits, under standard health care fee structures.
2. People who do not have a terminal illness can access assisted dying in some countries, but not all
A key distinction across countries is whether individuals with non-terminal conditions can access assisted dying, as is the case in Austria, Belgium, Canada, the Netherlands, Spain and Switzerland. In contrast, Australia, New Zealand, and US states restrict eligibility to those with terminal conditions, typically requiring a prognosis of 6 months or less (extended to 12 months for neurodegenerative conditions in most Australian states). Countries with broader eligibility criteria often impose additional safeguards to the assessment process – like requiring clinicians with relevant expertise to assess people’s cases. Across systems, cancer is typically the most common clinical diagnosis for people accessing assisted dying.
There are some eligibility criteria that are more common across systems. For instance, nearly all jurisdictions we reviewed require that: individuals accessing assisted dying experience unbearable suffering that cannot be alleviated; have sound decision-making capacity; and are making an informed, voluntary request. This means requests must be seen to be free from coercion or outside pressure. Most systems also mandate that individuals are informed of alternative options, including palliative care and broader end of life care services to provide symptom alleviation, psychosocial and emotional support. However, how these criteria are assessed and the process each involves varies considerably across systems, as discussed in section 3 below.
Key policy evolutions and trends
In some jurisdictions where assisted dying has been legal for longer – such as Canada (9 years), Belgium and the Netherlands (23 years in both) – eligibility has expanded over time. Sometimes this has occurred through formal legislative changes, often prompted by legal challenges; in other cases, policies and the way legislation has been applied has evolved in line with changing societal expectations, acceptance and norms. Of the systems we reviewed, we found no examples where eligibility became more narrow or restrictive over time, though some, such as Oregon in the US, have remained relatively consistent.
For instance, Canada – which legalised assisted dying in 2016 – broadened access to non-terminal conditions in 2021, following a legal case in 2019, and is preparing to allow assisted dying for people whose sole condition is a mental illness. Since this change, non-terminal cases have remained a small proportion of assisted deaths – 4% of assisted deaths (n=622) in 2023. However, in some other systems, the percentage has grown over time. In Belgium, where non-terminal conditions have been eligible since legalising assisted dying in 2002, the proportion has increased from 7% (n=24) in 2003 to 21% (n=718) in 2023.
Regardless of eligibility criteria, the proportion of total deaths which were assisted deaths has increased over time in most countries (see chart below), although assisted deaths make up a relatively small percentage of total deaths in any given year (0.1– 5.3% in 2023 across the countries we studied). Reasons for the increases and trends observed across systems are likely due to various factors embedded in the societal, ethical, political and legal contexts of each country.
For instance, processes for assisted dying take time to establish, and for the public to have awareness of the law and their rights to request access. Variation may also reflect evolutions to practice that broadened eligibility and access over time, as discussed above, or changing social norms and attitudes towards assisted dying in each place. Approaches to reporting assisted deaths and data quality also vary and may be underreported in some places. In Colorado, for instance, confirmed assisted dying deaths are not reported.
Most jurisdictions also impose residency requirements, limiting access to citizens or people who have been resident for at least one year, as a way of avoiding individuals travelling to or claiming residency in a place to access assisted dying. This raises further complications for countries where assisted dying is only legal in some states – like the US and Australia. Over time, some jurisdictions in these countries have eased restrictions or made exemptions – Australia, in part, due to broader legalisation across all six states, and to enable individuals to access the service closer to family.
3. Countries have all established processes for managing assisted dying, but safeguards and requirements vary
Every country where assisted dying is legal has established a structured process to assess eligibility and ensure consent. While these systems share common features, they differ in the specific safeguards used.
Consent and capacity
Most systems require multiple requests to confirm a patient’s consistent desire for assisted dying. Spain mandates a repeated request, in writing both times, while Colorado requires three distinct requests – at least one of which must be in writing. In addition to two written requests, Canada also mandates that individuals give final consent immediately before receiving assisted dying (though some exceptions apply). Some countries have also added safeguards like witness signatures or notarisation to prevent coercion – Austria, for example, requires a standardised dying decree to be signed in the presence of a notary or legal patient advocate, and all requests must be submitted using a standardised, digital form. The Netherlands is distinctive for not requiring a written request or witnesses.
Most systems also enforce a waiting period – either between requests for assisted dying, and/or between the final request and the provision of assisted dying – ranging from seven to 14 days. New Zealand and the Netherlands are less restrictive in that they do not have a mandatory wait. Other systems adjust waiting periods based on prognosis: Belgium imposes a one-month wait for non-terminal cases, but none for terminal conditions, while Austria requires a minimum of 12 weeks for non-terminal cases and two weeks for terminal ones. And in Canada, when death is not considered reasonably foreseeable, eligibility assessments must take at least 90 days (there is no mandatory wait period in cases where death is reasonably foreseeable).
Workforce requirements
After an individual formally requests assisted dying, at least two independent clinicians typically assess their eligibility. Most countries only authorise physicians to conduct these assessments and administer the procedure, though Australia, Canada, New Zealand, and parts of the US permit a broader range of professionals to be involved. For instance, in some Canadian provinces nurse practitioners are permitted to both assess eligibility and administer assisted dying medication. And in New Zealand, nurse practitioners may assist with care planning and administer the medication (though only medical doctors are authorised to assess eligibility).
Additional safeguards exist in some jurisdictions, such as requiring a third assessment for individuals with mental health conditions or uncertain decision-making capacity. Some countries that allow assisted dying for non-terminal conditions, like Canada, Austria and Belgium, mandate that at least one assessor should either have expertise in the condition causing suffering, or in palliative medicine.
Australia and New Zealand are distinct in implementing formal training in assisted dying protocols for clinicians to be able to provide the service (although in New Zealand this is applied by training being a condition of receiving reimbursement for delivering assisted dying services, rather than in legislation). Parts of Australia have also introduced other minimum qualification standards – for example, requiring doctors involved in assessing or providing assisted dying to either hold specialist registration with at least one year of clinical experience, or, for general practitioners, to have at least five years of clinical experience. New Zealand and some states in Australia are also unique in prohibiting staff from raising assisted dying with their patients – only individuals considering assisted dying can initiate the conversation.
Countries with less restrictive workforce requirements have similar training programmes, but they tend to be voluntary, as in Belgium, or rely more on clinical guidelines and standards, as in Switzerland. The Netherlands relies on expert clinical networks to support and advise practitioners, having established formalised centres of excellence to provide second opinions to assessments, rather than enforcing qualification requirements.
Every system allows health care professionals to refuse participation in assisted dying, but countries differ in how they balance this alongside ensuring patient access. Most require objecting practitioners to refer individuals to an alternative provider or coordination service, though enforcement varies – some Canadian provinces, for example, have no referral mandate.
Spain has a distinct approach whereby clinicians can morally object, but they must formally register their objection with state boards – essentially acting as an ’opt-out’ policy. Spain is also one of the few countries that explicitly prohibits institutional objection within the public health care system – meaning that state-funded organisations must ensure access to assisted dying for eligible individuals. This includes having systems in place to process requests and deliver assisted dying, even if this means bringing in external professionals or transferring individuals. Private institutions, particularly those with religious affiliations, have more flexibility to deny assistance. In most other systems, the right to moral objection only applies to individual practitioners.
Key policy evolutions and trends
A key tension that systems have had to manage is balancing adequate safeguards against ensuring timely access. This has led some jurisdictions – like Washington in the US – to broaden the range of professionals authorised to assess and oversee assisted dying requests to include physician assistants and advanced nurse practitioners. The state legislator enacted this change partly in response to concerns from advocates that individuals in rural areas struggled to access assisted dying due to limited numbers of physicians in these areas. Similar policies have been introduced in Colorado.
Other systems have reduced the mandatory waiting period, as in California – which reduced its 15-day waiting period between requests for assisted dying to 48 hours in 2022 – and Colorado, which halved its waiting period between requests from 15 to 7 days in 2024, and allowing providers to waive it entirely if death is imminent. Following a legal case and public consultation, Canada amended its law to remove the 10-day reflection period requirement for people whose natural death is reasonably foreseeable.
To ensure individuals are better informed about their options, some systems have also introduced requirements for health care institutions, like hospices, to publicly disclose their assisted dying policies. California recently adopted this approach, and it is under consideration elsewhere. Belgium took a further step in 2020, banning institutional objection to euthanasia, and strengthening requirements for objecting professionals to inform individuals of their options and refer to alternative providers.
Data is limited, but where available 1 it shows general practitioners as the most common staff group involved in assisted dying. Generally, it seems that most clinicians participate in only one or two cases a year, while a small group is then responsible for a significant proportion. For instance, in 2023 in Canada, just 4% of practitioners (89 in total) handled 64% of all cases (providing assisted dying 31 or more times each). Likewise, in Oregon in 2023, 77% of physicians that had prescribed medication for assisted dying wrote only one or two prescriptions.
4. The emphasis on prospective versus retrospective review differs across countries
Many systems have established formal boards and committees to provide oversight and assurance to assisted dying decisions, though there are differences in how these bodies function and at what stage they fit into the process. Likewise, countries vary in what data is required to be recorded about assisted dying, and if and how this is integrated with existing death registration processes.
While many systems have a form of retrospective review, the Netherlands is distinct for the pivotal role it gives to this process. Other systems tend to combine stricter upfront procedures and processes alongside retrospective reviews as safeguards, where the Dutch model primarily relies on thorough oversight after the fact to ensure ethical and legal compliance. In the Netherlands, all assisted deaths must be reported to a municipal coroner, who forwards cases to regional committees composed of lawyers, doctors and ethicists. These regional committees review every case to ensure adherence to all legal and ethical standards, and that practitioners have demonstrated full duty of care. Although Belgium, Spain, Canada and New Zealand also use retrospective review, the scope and approach varies – for instance, Ontario in Canada has set up an enhanced review committee that focuses on complex cases, while New Zealand primarily checks for administrative and operational compliance.
In Spain, New Zealand, and some Australian states, the entire case must first be considered by a registrar, review board or committee before medication can be administered and final approval given. These independent boards are often also tasked with data collection and monitoring uptake of assisted dying, as well as compliance with legislation.
Conclusion
The debate on assisted dying is often shaped by selective interpretations of international evidence, with the same country’s experience used to argue both for and against legalisation. This review does not make a judgement about the effectiveness of different models, but rather highlights the vast variation in how assisted dying has been implemented, reflecting each country’s unique ethical, political and legal landscape.
These differences are not just procedural – they affect how individuals access and experience services, what roles and responsibilities professionals hold, and how safeguards are upheld. As assisted dying legislation is considered in the UK, the diverse experiences of other countries offer critical learning. Our future work will delve deeper into the operational and system challenges that jurisdictions have faced in implementation, with key lessons for the UK as it considers its own path.
Sources
The list of country level data sources and policy documents that informed the table and chart.
Australia
Victoria
- Victoria Department of Health, Voluntary Assisted Dying Five-Year Review, 2024.
- Voluntary Assisted Dying Review Board Annual Report, July 2023-June 2024.
Voluntary Assisted Dying Review Board Annual Report, July 2022-June 2023.
Voluntary Assisted Dying Review Board Annual Report, January- June 2021.
Voluntary Assisted Dying Review Board Annual Report, July- December 2020.
Voluntary Assisted Dying Review Board Annual Report, January – June 2020.
Voluntary Assisted Dying Review Board Annual Report, June – December 2019.
Voluntary Assisted Dying Review Board Annual Report, 2018-19.
All available at the Department of Health, Voluntary Assisted Dying Review Board.
Queensland
- Queensland Voluntary Assisted Dying Act, 2021.
- Queensland Voluntary Assisted Dying Review Board Annual Report, 2023-2024. Queensland Voluntary Assisted Dying Review Board Annual Report, 2022-2023.
All available at Queensland Health, Voluntary Assisted Dying Review Board annual reports.
Western Australia
- Western Australia Voluntary Assisted Dying Act, 2019.
- Voluntary Assisted Dying Board Western Australian Annual Report, 2023-24. Voluntary Assisted Dying Board Western Australian Annual Report, 2022-23. Voluntary Assisted Dying Board Western Australian Annual Report, 2021-22.
All available at Department of Health, Voluntary Assisted Dying Board Annual Report.
Austria
- Federal Act on Assisted Dying (Sterbeverfügungsgesetz, StVfG) Federal Law Gazette (Bundesgesetzblatt) BGBl. I Nr. 242/202).
- Federal Ministry of Labour, Social Affairs, Health, Care and Consumer Policy, Dying Will Practical Implementation Guide, 2024.
Belgium
Canada
- Bill C-14, An Act to amend the Criminal Code and make related amendments to other Acts (Medical Assistance in Dying), 2016.
- Bill C-7, An Act to amend the Criminal Code (Medical Assistance in Dying), 2021.
- Health Canada, Annual Reports on Medical Assistance in Dying in Canada, (2019 through 2023).
- Health Canada, Model Practice Standard for Medical Assistance in Dying, 2023.
- Health Canada, Medical assistance in dying: Implementing the framework.
- Parliament of Canada, Medical assistance in dying: a patient-centred approach: Report of the Special Joint Committee on Physician-Assisted Dying, 2016.
- Parliament of Canada, Medical assistance in dying in Canada: Choices for Canadians: Report of the Special Joint Committee on Medical Assistance in Dying, 2023.
Netherlands
- Netherlands Central Government, Euthanasia and the law; Dying with the assistance of a doctor.
- Regional Euthanasia Committee Annual Reports (2023 through 2010).
- ZonMw, Fourth Evaluation report on the Dutch Termination of Life on Request and Assisted Suicide Review Act (Wtl) 2017-2022.
- ZonMw, Third Evaluation report on the Dutch Termination of Life on Request and Assisted Suicide Review Act (Wtl) 2012-2016.
New Zealand
- End of Life Choice Act, 2019.
- Health New Zealand, Assisted Dying Services.
- Health New Zealand, Assisted Dying Service Annual Reports (2021 through 2024).
- Ministry of Health, Review of the End of Life Choice Act 2019, 2024.
Spain
- Organic Law 3/2021, of March 24, Regulation of Euthanasia.
- Ministry of Health, Annual Reports on the Provision of Aid in Dying (2021 through 2023).
Switzerland
- Federal Statistics Office, Cause of Death Statistics.
- Dignitas and Swiss Federal Statistical Office, Life Expectancy, Suicide, Assisted Suicide, Deaths, Population in Switzerland since 1969.
- Swiss Academy of Medical Sciences, Management of dying and death, 2021.
United States
California
- Assembly Bill-15 (End of Life Option Act).
- Senate Bill-380 (End of Life Option Act).
- California Department of Public Health, California End of Life Option Act Data Reports (2016 through 2023).
Colorado
- Senate Bill 24-068, Colorado End-of-Life Options Act.
- Colorado Department of Public Health and Environment, Colorado End-of-Life Options Act annual statistical reports (year 2017 through 2023).
New Jersey
- New Jersey Medical Aid in Dying for the Terminally Ill Act (P.L. 2019, c. 59).
- NJ Health, New Jersey Medical Aid in Dying for the Terminally Ill Act data summaries (2019 through 2023).
Oregon
- Senate Bill 579, Oregon Death with Dignity Act.
- Senate Bill 22779, Oregon Death with Dignity Act.
- Oregon Health Authority. Death with Dignity Act annual reports (2010 through 2024).